Care of the Senior AthleteOlder athletes want to remain vital and competitive

p 3

Geriatric TimesAn Update for Physicians from Cleveland Clinic’s Medicine Institute | Fall 2013

Anterior Approach to Total Hip Arthroplastyp 6

Reverse Total Shoulder Replacementp 8

Sleep Apnea in Older Adultsp 11

Evaluating the Older Patient with Dementia p 13

AlSO in THiS iSSuE

Dear Colleagues:It is my great pleasure in each issue of Geriatric Times to highlight the Cleveland Clinic specialties that help us improve the care of our oldest patients.

Deciding where to send patients who need comprehensive geriatric care can be difficult. In the Center for Geriatric Medicine, our goal is to improve care for the oldest and frailest members of society by serving as a central resource for geriatric and gerontological clinical, educational and research activity.

We advise, educate and assist physicians, nurses, therapists, social workers, other clinical providers and caregivers across our system of eight hospitals and 16 family health centers. We coordinate programs and are contributing to the Cleveland Clinic care paths being developed for delirium and other age-related conditions.

In this issue, we highlight the efforts of Cleveland Clinic orthopaedic specialists to keep older patients as active as possible:

• The mature athlete. Dr. Alfred Cianflocco, who was involved in the 2013 National Senior Games held in Cleveland in July, discusses the physiologic changes associated with aging, and the care and follow-up that mature athletes require.

• Anterior approach to total hip replacement. Drs. Carlos Higuera-Rueda and Pratik Desai explain which older patients may benefit from anterior total hip arthroplasty, which offers a shorter hospital stay and early functional recovery.

• Reverse shoulder surgery. Drs. Joseph Iannotti and Eric Ricchetti review reverse shoulder surgery, which allows many frail elders to resume their upper-body activities of daily living.

We also address two other important issues affecting many elderly patients:

• Sleep apnea. Dr. Harneet Walia discusses how diagnosing and treating sleep apnea in older adults can avert adverse long-term health consequences.

• Self-care in patients with dementia. Licensed social worker Rosemary Truchanowicz describes warning signs that physicians should recognize in patients with dementia and caregivers.

These articles represent a small sample of the work we do every day to help make a real difference in the quality of our patients’ lives.

We look forward to continuing our partnership with you. Please don’t hesitate to contact me at 216.444.6801 or rapporb@ccf.org with any questions, concerns or suggestions on how we might improve future services to you and your patients.

Kind regards,

Barbara Messinger-Rapport, MD, PhD, FACP, CMD

Director, Center for Geriatric MedicineCleveland Clinic Medicine Institute

Medical Editor Barbara Messinger-Rapport, MD, PhD

Managing Editor Cora M. Liderbach

Art Director Anne Drago

Cover Photo Steve Travarca

Geriatric Times is published by the Center for Geriatric Medicine, within Cleveland Clinic’s Medicine Institute. The institute also encompasses Family Medicine, Internal Medicine, Infectious Disease, Primary Care Women’s Health, and one of the nation’s largest Hospital Medicine programs. Primary care providers within the institute use the patient-centered medical home model to coordinate basic, chronic and complex care for patients at the main campus and 16 family health centers.

The Medicine Institute is one of 27 institutes at Cleveland Clinic, a nonprofit academic medical center ranked among the nation’s top hospitals by U.S. News & World Report. More than 3,000 physicians and researchers in 120 specialties at Cleveland Clinic collabo-rate to give every patient the best outcome and experience.

Geriatric Times is written for physicians and should be relied on for medical education purposes only. It does not provide a complete overview of the topics covered and should not replace the independent judgment of a physician about the appropriateness or risks of a procedure for a given patient.

© 2013 The Cleveland Clinic Foundation

Cleveland Clinic’s Center for Geriatric Medicine is ranked the No. 7 geriatrics program in the country by U.S. News & World Report.

For details, visit clevelandclinic.org.

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c l e v e l a n d c l i n i c . o r g / g e r i a t r i c m e d i c i n e

Care of the Senior Athlete Improving strength, endurance, flexibility and performance

By Alfred Cianflocco, MD

cOvER

STORy

The effects of aging on the musculoskeletal, cardio-

vascular, pulmonary, hematologic, neurologic and

metabolic systems can all impact the ability to exercise.

Musculoskeletal changes alone decrease muscle mass,

bone mass and tensile strength in ligaments and tendons;

stiffen muscles, tendons and ligaments; and weaken

articular cartilage.

Yet aging alone does not account for all these changes; a

decline in physical activity is also responsible. Many age-

related changes faced by senior athletes can be limited,

reversed or prevented, allowing them to continue to exercise.

Aging, physiologic changes and exercise

The slow, progressive decline in athletic performance

with aging accelerates after age 60. Contributing factors

include:

• Increasingly prevalent medical conditions

• Musculoskeletal conditions and injuries

• Longer recovery from training sessions

• Hormonal changes influencing exercise response

• Changes in motivation

• Lack of time for, and suboptimal, training

Risk of musculoskeletal injury

Orthopaedic injury risks increase among senior athletes

with previous joint injuries, underlying osteoarthritis, or

sensory impairment from altered proprioception, vestibu-

lar function, vision or hearing.

Overuse injuries are more common due to a longer recov-

ery time and training errors. Age-related musculoskeletal

changes make lumbar disc disease, osteoarthritis and the

following injuries common:

• Muscle strains. These are the most common injuries

seen with aging and tend to occur acutely, especially in

strength and power sports. Increased muscle stiffness

is the primary cause.

• Tendinopathy. The patellar tendon, rotator cuff and

Achilles tendon are commonly affected sites. Age-

related decreases in tendon flexibility and tensile

strength, degenerative changes with repetitive loading,

and decreases in blood supply are predisposing factors.

• Degenerative meniscal tears with osteoarthritis of the

knee. These are often seen together. Meniscal tears can

occur with minimal trauma in arthritic knees, contrib-

uting to osteoarthritic progression.

Risk of temperature-related illness

Age-related physiologic changes make it harder to adapt to

temperature changes. During exercise, older athletes are

more prone to:

• Heat illness — from an increased risk of dehydration,

decrease in sweat gland function, impaired increase in

skin blood flow with elevated core temperatures, and

effects of beta-blockers, diuretics or other medications.

• Cold injury — from an impaired perception of ambient

temperature and vasoconstrictor response, autonomic

dysfunction, and a decreased capacity for thermogen-

esis through shivering

care of musculoskeletal injuries in older athletes

The initial management of musculoskeletal injuries —

protection, rest, ice, compression and elevation — is the

same for all ages. For both older and younger athletes,

delayed evaluation and treatment can produce injury chro-

nicity, complicated rehabilitation, delayed recovery and

unnecessary time lost from the activity.

Older adults tend to be less active as a group, but many remain or choose to become active. The increasing popularity of

the National Senior Games shows that the number competing individually and on teams is rising. These highly motivated

athletes require guidance on training, injury prevention and care, and performance.

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G e r I AT r I C T I M e s | FA L L 2 0 1 3

Appropriate treatment for musculoskeletal sports-related

injuries does not stress an aging body.

studies consistently demonstrate delayed healing of mus-

culoskeletal injuries in older adults. However, older adults

can respond to active and progressive rehabilitation.

relative rest and activity modification (avoiding total

inactivity, which can lead to loss of flexibility, strength and

bone mass, and cardiac deconditioning) are key.

Physical therapy — focusing on range of motion, flexibil-

ity, strength and proprioception, and alternative training

methods — is essential for a safe, timely return to activity.

(Fewer than 5 percent of musculoskeletal injuries require

surgery at any age.)

Medical evaluations

required before and after athletic participation, medical

evaluations are based on age, underlying health problems

and plans for activity. The major objectives are to identify:

1. Underlying medical conditions that may limit the ability

to exercise or increase the risk of significant medical

events with activity

2. Musculoskeletal or other medical issues, such as

balance or vision problems, that could limit participa-

tion or increase injury risks

Preventive measures

Injury prevention may be more important for senior than

for younger athletes, but prevention guidelines are similar.

strength, flexibility and neurophysiologic capacities

should be ensured prior to the activity. Activities that may

aggravate an underlying condition, such as high-impact

exercise in athletes with osteoarthritis of the spine or

lower extremities, should be modified or avoided.

surface conditions cannot be overlooked; soft surfaces can

reduce impact on lower extremities, while uneven surfaces

place senior athletes with balance problems at risk.

The basics of injury prevention apply to athletes of all ages

and include:

• Proper warm-up with adequate cool-down after activity

• Avoidance of abrupt changes in frequency, duration and

intensity of activity

• Allowance for adequate recovery time by alternating

days of intense activity with less strenuous activity

• Adjusting for environmental conditions such as tem-

perature and humidity

Age-related physiologic changes can impact nutritional

and fluid requirements, and the ability to meet these

needs. Proper nutrition and hydration are key to optimal

performance for all athletes.

The bottom line: By applying many of the same training,

injury management and prevention guidelines used for

younger athletes to our senior athletes, we physicians can,

with a few special considerations, help them continue to

compete optimally and safely. n

Dr. Cianflocco, of Cleveland Clinic’s Department of Orthopaedic Surgery, specializes in nonop-erative orthopaedics, sports medicine, and neck and back problems. He may be reached at 216.692.7750 or at cianfla@ccf.org.

Care of the Senior Athlete continued

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c l e v e l a n d c l i n i c . o r g / g e r i a t r i c m e d i c i n e

“Men do not quit playing because they grow old. They grow old because they quit playing.”

Oliver Wendell Holmes wrote it. E. Michael Loovis, PhD, lives by it.

“People who understand that staying active is an important part of my life are less likely to say, ‘You’ve had a full life. Why not take some time and relax?’” says the 67-year-old health and physical education professor.

Dr. Loovis, a former high school and college athlete, physical education teacher and coach, has taught in the Department of Health and Human Performance at Cleveland State University for 35 years. He remains active with weight training, the elliptical and the treadmill, and takes yoga classes with his wife.

But his real passion is squash.

After arthroscopic knee surgery by Cleveland Clinic Sports Health surgeon James Williams, MD, several years ago, Dr. Loovis was itching to get back on the court. But osteo-arthritis slowed his recovery, and jogging, running and climbing steps were painful.

When Dr. Williams recommended knee replacement, “I asked him what it would do to my squash game,” says Dr. Loovis. Learning he’d be permanently sidelined, Dr. Loovis declined surgery. However, he agreed to another sugges-tion from Dr. Williams: viscosupplement injections. Four years later, he still gets injections in both knees every six months and has avoided surgery.

Dr. Loovis credits his doctors for offering treatments that allow him to enjoy the game he loves. He plays squash three days a week and has no plans to slow down.

“Hitting the winning shot in a match would be the perfect way to go,” he says.

CASE StuDy:

Aging Athlete Wants to Keep Playing

5

Anterior Approach to Total Hip Arthroplasty Benefits include less tissue damage, better positioning

By Pratik P. Desai, MD, MS, and Carlos Higuera-Rueda, MD

T otal hip arthroplasty is considered one of the most successful procedures of our modern surgical era. It improves quality

of life, has an excellent success rate, relieves pain and restores mobility. We have found that using an anterior approach

to total hip arthroplasty minimizes tissue damage and pain, and leads to a quicker recovery.

The majority of hip arthroplasty procedures have used a

posterior approach. The direct anterior approach to hip

arthroplasty, first described in 1917, was not used exten-

sively until recently due to technical concerns and the

experience required.

Minimally invasive: Minimal tissue damage

Minimally invasive surgery was introduced to orthopae-

dics in the 1970s in the form of arthroscopy and later

employed in open surgical procedures. Interest in mini-

mally invasive approaches to total hip arthroplasty has

resurfaced in recent years, with increased attention to the

anterior approach.

Perhaps more important than the implied shorter incision

length is reduced damage to muscle and tissues within the

operative field. In theory, less muscle damage leads to less

pain and a quicker recovery from surgery. This theory is

corroborated in the outcomes table on page 7.

Using internervous or intermuscular planes is one way

to decrease tissue damage, and the anterior approach to

total hip arthroplasty follows this principle. The posterior

approach can be minimally invasive in terms of a smaller

incision and reduced exposure, but it does not use an

internervous or intermuscular plane.

In 2011, Bergin et al compared the results of the minimally

invasive anterior approach and the posterior approach to

total hip arthroplasty. In particular, they evaluated the rise

of muscle damage markers and inflammatory markers.

Levels of serum creatine kinase (an indicator of muscle

damage) were 5.5 times lower than markers of inflamma-

tion (CrP, IL-6, IL-1, TNF-alpha) in the anterior approach

group compared to the posterior approach group.

Better positioning with the anterior approach

Most traditional approaches to total hip arthroplasty

employ the widely used lateral decubitus position with

great success. However, this position makes access to the

extremities — and therefore intravenous access — more

challenging for anesthesia personnel.

In addition, airway access becomes more difficult. This

poses challenges for pulmonary hygiene during the proce-

dure and for conversion from spinal to general anesthesia,

if needed.

Anterior total hip arthroplasty is performed in the more

traditional supine position. This allows for easier patient

suctioning/pulmonary hygiene and easier intravenous

access. In addition, accurately assessing leg lengths is

easier in the supine position.

Experience helps avoid complications

Anterior total hip arthroplasty is not appropriate for every

patient, especially at the beginning of a surgeon’s learn-

ing curve. To prevent complications, the surgeon must

carefully select patients for the procedure and must have

ample experience with this exposure.

The anterior approach increases the risk of injury to the

lateral femoral cutaneous nerve. The incidence of meral-

gia paresthetica has been 17 percent in some studies. In

addition, femoral exposure can prove difficult; several

series have demonstrated an approximately 2 percent risk

of iatrogenic femoral fractures.

Careful examination of physical characteristics is key, as a

large pannus in an obese patient may predispose to wound

breakdown, hematoma or infection.

To avoid compromising the lateral femoral cutane-

ous nerve, we prefer a modified version of the anterior

approach that uses a more lateral muscle interval, between

G e r I AT r I C T I M e s | FA L L 2 0 1 3

6

Table: Total Hip Arthroplasty Outcomes

the tensor fascia lata and the gluteus medius. This interval

may improve hip joint exposure and can be extended

should complications such as femur fractures occur.

Easier recovery with anterior approach

Many studies have documented a faster recovery with less

pain after anterior total hip replacement. A recent 2013

study retrospectively comparing the anterior and posterior

approaches found that mean hospital stay (2.9 vs. 4 days)

and days to patient mobilization (2.4 vs. 3.2 days) were

significantly shorter with the anterior approach.

The surgical literature has repeatedly demonstrated faster

recovery with the anterior approach in the early weeks

after surgery. At six and 12 weeks after anterior total hip

arthroplasty, patients progress faster through more gait

and rehabilitation parameters than with conventional

hip approaches.

Posterior approach (lateral decubitus position)

Anterior approach (supine position)

Risk of femoral fracture during surgery 1%-2% 2%-4%

lateral cutaneous femoral nerve symptoms < 1% 2%-20%

Risk of dislocation in the first year 3-4% < 1%

Functional outcomesLower in the first 3 months; similar at 12 months

Higher up to 3 months after surgery

Mean hospital stay (days) 4 2.9

Discharge to home vs. rehab facility 84% 97%

c l e v e l a n d c l i n i c . o r g / g e r i a t r i c m e d i c i n e

In addition, the use of assistive devices (crutches, canes,

walkers) is significantly less in the short term with the

anterior approach.

Because the learning curve is steep for minimally invasive

anterior total hip arthroplasty, it is best to refer patients to

surgeons who have performed a minimum of 40 proce-

dures or who have spent six months in a high-volume hip

arthroplasty center.

For references, please contact the authors. n

Dr. Desai (left) is a fellow and Dr. Higuera (right) is a staff physician in the Section of Adult Reconstruction in the Department of Orthopaedic Surgery. Dr. Desai can be reached at desaip2@ccf.org, and Dr. Higuera at higuerc@ccf.org or at 216.636.1136.

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G e r I AT r I C T I M e s | FA L L 2 0 1 3

Many patients with shoulder pain have arthritis or rotator cuff tears. Some patients develop both severe arthritis and

large rotator cuff tears. This combined pathology results in severe pain and marked loss of function — in particular,

the inability to actively raise the arm overhead (Figure 1A).

Reverse Total Shoulder Replacement A useful alternative for older patients

By Joseph P. Iannotti MD, PhD, and Eric T. Ricchetti, MD

reverse total shoulder replacement is the best option

for patients failing nonoperative management of

severe arthritis and a large rotator cuff tear (Figure 1B).

specifically designed to address this clinical scenario,

reverse total shoulder replacement is generally performed

in patients who are in their mid- to late 60s or older.

Standard approach inadequate

In standard shoulder replacement for arthritis, the

convex side of the joint (on the humerus) is replaced with

a new metal ball, and the concave side of the joint (on the

scapula) is resurfaced with a new plastic socket.

This eliminates pain and improves function but relies on

a well-functioning rotator cuff for optimal results and may

work poorly in the presence of a large rotator cuff tear.

A change in position

In reverse replacement, the concave and convex surfaces

of the shoulder joint are placed on the opposite sides of

the normal shoulder. A metal hemisphere is placed on the

socket, and a metal and plastic socket is used to replace

the ball (Figure 2). Despite the large rotator cuff tear, the

change in position improves shoulder function by replac-

ing the joint and removing any arthritis.

The FDA-approved reverse prosthesis, introduced in the

United states in 2004, has proved to be a reliable option for

patients who previously had no surgical solution. More than

90 percent of patients experience significant improvement

in both shoulder pain and function, including restoration of

overhead arm function. Ten years after reverse replacement,

implant survival is approximately 90 percent, which is com-

parable to the rate at 15 years after standard replacement

(longer follow-up is not available).

Patient indications expand

Use of the reverse prosthesis is increasing, and its appli-

cations have broadened to include patients requiring

shoulder replacement due to significant rotator cuff dys-

function for other reasons. These include:

• Failed or revision shoulder replacement

• Treatment of complex proximal humerus fractures

requiring shoulder replacement

Failure of a prior shoulder replacement is often associ-

ated with rotator cuff deficiency, either from damage to

the rotator cuff itself or because bone loss led to damage

or destruction of the rotator cuff’s bony attachment sites

(Figure 3). Acute or chronic proximal humerus fractures

FiguRE 1

A: Patient is unable to raise her arm overhead due to advanced arthritis and a large rotator cuff tear.

B: Typical radio-graphic changes seen when advanced arthritis develops due to a massive, irreparable rotator cuff tear.

8

c l e v e l a n d c l i n i c . o r g / g e r i a t r i c m e d i c i n e

may also be associated with rotator cuff deficiency if the

fracture causes severe damage to the bony attachment sites.

In both situations, surgical treatment can be difficult, and

standard shoulder replacement may not reliably improve

pain and function. reverse total shoulder replacement has

shown promise in more reliably improving shoulder func-

tion in these challenging clinical scenarios.

Speeding recovery

Patients who undergo reverse total shoulder replace-

ment are generally hospitalized for two to three days after

surgery. Physical therapy stretching exercises are started

the day after surgery, and patients are encouraged to use the

operative hand and elbow at waist level for activities of daily

living, including eating, bathing, dressing, typing, etc.

Most patients are discharged to home with a sling and

are asked to discontinue its use within the first few days

of surgery. Most patients are allowed to drive a car with

an automatic transmission within two to three weeks

of surgery.

Rehabilitation at home

shoulder- and arm-stretching exercises are done by

the patient each day at home after leaving the hospital.

Patients progress to strengthening exercises for the shoul-

der and arm as early as six weeks after surgery, and most

patients complete physical therapy within six months after

surgery. Limits on lifting and pushing with the operative

arm are kept in place for six months after surgery.

LEfT: fIguRE 2

Anteroposterior (A) and axillary (B) plain radiographs of a reverse total shoulder replacement dem-onstrate how a metal hemisphere is placed on the old socket, while a metal and plastic socket replaces the old ball.

ABovE: fIguRE 3

A: Plain radiograph shows rotator cuff deficiency and superior migration of the humeral prosthesis after standard total shoulder replacement elsewhere. B: Postoperative radiograph after revision to reverse total shoulder replacement at cleveland clinic.

9

When these events occur, results are not as favorable.

Many patients require additional surgery to correct the

problem, including potential revision or removal of the

implant if necessary.

As the use of reverse total shoulder replacement in clini-

cal practice increases, further knowledge about optimal

implant placement and design will lead to improved clini-

cal function, fewer complications and longer prosthesis

survival. n

Dr. iannotti (left), chairman of the Orthopaedic & Rheumatologic institute, can be reached at iannottj@ccf.org or 216.445.5151; Dr. Ricchetti (right), of the institute’s Hand and upper Extremity center, can be reached at ricchee@ccf.org or

216.445.6915.

G e r I AT r I C T I M e s | FA L L 2 0 1 3

Reverse Total Shoulder Replacement continued

Adherence to postoperative restrictions and the rehabili-

tation protocol help to decrease the likelihood of adverse

events. While reverse total shoulder replacement reli-

ably improves pain and function, and implant longevity

approaches that of standard shoulder replacement, surgi-

cal complications can occur.

Potential adverse events

Adverse events take place in about 10 percent of patients

undergoing reverse total shoulder replacement. The most

common are:

• Postoperative hematoma in up to 4 percent

of patients

• Infection in 1 percent of patients

• Dislocation in 3 percent of patients

• stress fracture of part of the scapula in 2 percent

of patients

• Nerve injury in less than 1 percent of patients

Table: Total Shoulder Replacement — Comparing Reverse and Standard Approaches

Reverse total shoulder replacement Standard shoulder replacement

Typical indications for surgery

Massive, irreparable rotator cuff tear with or without shoulder arthritis; failing nonoperative management

Shoulder arthritis in the absence of a rotator cuff tear; failing nonoperative management

Most common patient characteristics

Male and female; ages 60 and above; independent ambulators

Male and female; ages 50 and above; independent ambulators

Typical outcomes Outstanding pain relief; improvement in overhead function and overall shoulder range of motion (may gain less overhead function than with standard replacement, and some weakness related to rotator cuff tear may persist)

Outstanding pain relief; improvement in overhead function and overall shoulder range of motion

implant longevity Approximately 90% at 10 years (longer follow-up not yet available)

Approximately 90% at 15 years

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Sleep Apnea in Older Adults Obstructive and central sleep apneas should be treated at any age

By Harneet Walia, MD

sleep apnea, a common sleep disorder in the elderly, should be treated to avoid adverse consequences. Of the two types —

obstructive sleep apnea (OSA) and central sleep apnea (CSA) — OSA is more prevalent, affecting approximately 15 percent

of all adults and up to 60 percent of older adults. CSA, while less common, becomes more prevalent with advancing age.

In OSA, decreased upper airway muscle tone during sleep

causes repetitive, complete (apnea) or partial (hypopnea)

upper airway closure despite continued thoracoabdominal

effort. Episodes lead to interrupted, poor-quality sleep and

oxygen desaturation. Older men and women are equally

susceptible; at younger ages, men are more susceptible.

In CSA, decreased airflow and ventilatory effort in the

absence of upper airway collapse can lead to sleep disrup-

tion. Related either to hyperventilation or hypoventilation,

CSA is more common among older men than women.

Sleep apnea severity is defined using the apnea-hypopnea

index (AHI), or average number of apneas and hypopneas

per hour of sleep. An AHI of 5-<15 indicates mild sleep

apnea, an AHI of 15-<30 indicates moderate sleep apnea,

and an AHI ≥ 30 indicates severe sleep apnea.

Risk factors for OSA in the elderly include:

• Increased weight

• reduced lung function

• Impaired ventilatory control

• Increased upper airway collapsibility

• Changes in sleep architecture (e.g., reduction in slow-

wave sleep, considered protective for OsA)

• Decreased hormone levels in older women, which

appear to contribute to increased airway collapsibility

OsA in the elderly is also associated with use of sedat-

ing medications or alcohol, family history, ethnicity and

smoking. sedatives and narcotics can decrease the respira-

tory drive, worsen upper airway collapsibility during sleep

and increase apnea severity.

CsA can be primary or secondary to neurological disorders

such as stroke, or to heart failure (Cheyne-stokes respira-

tion), opiod use or high-altitude breathing.

clinical manifestations

The main symptoms of OSA at younger ages are snoring,

witnessed apneas, choking or gasping for air, excessive

daytime sleepiness and disrupted sleep. In addition to

these, symptoms related to OSA at older ages may include

nocturia, cognitive impairment and repeated falls.

These symptoms can significantly affect daytime func-

tioning but are usually attributed to normal aging and

may not be brought to the clinician’s attention.

CSA can cause excessive daytime sleepiness. Secondary

CSA usually produces symptoms related to the comorbid-

ity. For example, patients with Cheyne-Stokes respiration

have signs and symptoms associated with heart failure.

OSA and its consequences

OSA severity is positively related to cardiovascular disease

development and to the severity of dementia. One theory

explaining the association with cognitive decline in the

elderly is that OSA accelerates the brain’s aging process.

Hypoxemia, sleep fragmentation, endothelial dysfunc-

tion, increased transmural pressure, sympathetic activity,

inflammatory markers and oxidative stress appear to be

the mechanisms involved in the cardiovascular conse-

quences of OSA. Some of these mechanisms may stimulate

the natriuretic hormones, causing nocturia.

OSA can impair attention, concentration and recall func-

tioning and cause memory decline. Severe OSA (AHI > 30

events/hour) can cause deficits in recall functioning, exec-

utive functioning, and planned and sequential thinking.

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G e r I AT r I C T I M e s | FA L L 2 0 1 3

Sleep Apnea in Older Adults continued

sleep apnea can also be associated with depression-like

symptoms. Moderate-to-severe OsA and excessive daytime

sleepiness are risk factors for mortality in older adults.

Sleep apnea assessment

Assessment should include a comprehensive sleep history

focusing on snoring, on symptoms of excessive daytime

sleepiness (such as unintentional napping while reading,

watching TV, conversing or driving) and on a history of

irregular sleep-wake cycle or nocturia.

Obtaining a history from bed partners or caregivers is

prudent. It is also important to consider other sleep disor-

ders, such as restless legs syndrome, insomnia, circadian

rhythm disorders and abnormal sleep behaviors. The

medical history should include comorbidities, medication

history, and personal history of alcohol and drug usage.

If the assessment suggests OsA, an overnight lab poly-

somnogram or home sleep testing can help confirm the

diagnosis. (Home sleep testing is reserved for patients

without significant comorbidities or other sleep disorders

and who are younger than 65.) If the assessment suggests

CsA, an in-lab polysomnogram is recommended.

Positive airway pressure therapy

Continuous positive airway pressure (CPAP) is the treat-

ment of choice for moderate-to-severe OSA. Bi-level positive

airway pressure (BiPAP) and automatic positive airway pres-

sure devices may help those who cannot tolerate CPAP.

In CsA, bi-level positive airway pressure with backup rate

(BiPAP s/T) and adaptive servo-ventilation (AsV) devices

are helpful if CPAP has failed. However, the underlying

cause must be treated — for example by optimizing heart

function in patients with Cheyne-stokes respiration or by

discontinuing opioids in opioid-induced CsA.

CPAP works by holding the airway open using a pneumatic

splint. This improves sleep architecture, daytime sleepi-

ness, symptoms such as snoring and gasping for air, motor

speed, nonverbal learning and memory.

There is evidence that CPAP improves vascular resistance,

mitigating the effects of OSA-induced hypertension, and

that it may reduce nocturia by allowing normal nocturnal

release of antidiuretic hormone. Sustained long-term

CPAP therapy may slow cognitive decline in Alzheimer

disease. However, more definitive data is needed to under-

stand the effects of treatment on cognitive decline.

compliance and follow-up

Because CPAP compliance is similar at younger and older

ages, age alone is not a factor. However, cognitive impair-

ment, medical comorbidities, nocturia, lack of support

and impaired dexterity may affect CPAP compliance at

older ages. Behavioral interventions can be helpful.

Older adults on positive airway pressure devices require

regular follow-up with their sleep physician or geriatrician

to monitor progress and check on compliance.

Other options for OSA

Other OSA treatment options, including oral appliances

and surgery, have not been well-studied in the elderly. Oral

appliances are not always the best choice because ade-

quate dentition is required to properly position them.

Conservative treatments should be emphasized in this

population and include weight loss, avoiding supine sleep,

abstaining from alcohol and drugs such as benzodiaz-

epines and opioids, and treating nasal congestion. n

Dr. Walia, of the cleveland clinic neurological Institute’s Sleep Disorders Center, can be reached at 216.636.5860 or waliah@ccf.org.

12

Changes in executive functioning that affect abstract

reasoning, planning and judgment may occur so slowly

that they are not appreciated by caregivers. Deficits may be

minimized until they are of such severity that they endan-

ger the patient.

SOS for seniors

To prevent adverse incidents, we recommend assessing

three areas of function in the older patient with dementia:

self-care, outlook on life and support network (SOS). Doing

so will allow clinicians to:

• Identify deterioration in functioning or mood and

potentially dangerous situations

• Make appropriate recommendations

• suggest interventions

Questioning caregivers

It’s important to carefully question older patients with

dementia and their caregivers about self-care. For example:

• Appearance and hygiene. Does the caregiver need to

prompt the patient to shave, bathe or change clothes? Is

there less attention to hygiene, are the same clothes worn

daily, or have standards of dress and grooming slipped?

• Aid required. How much assistance, and what kind,

does the caregiver provide? Does the older patient with

dementia resist assistance, verbally abuse the caregiver

or become agitated due to confusion? If so, the medica-

tion regimen should be re-evaluated and a home safety

evaluation recommended to gather data to ameliorate

the situation.

For example, bathing may be an exhausting routine for a

caregiver and a frightening event for the patient. This is

particularly true for older females, who tend to provide

more personal care to spouses than do older males.

Evaluating the Older Patient with Dementia Part 1: Assessing Self-Care and Caregiving

By Rosemary Truchanowicz, MSW, LISW-S, BCD, C-SWHC

The unpredictable road traveled by patients with dementia and their caregivers can bring gradual or precipitous

changes in personality, cognition and functioning. Older patients with poor insight may not comprehend that more

assistance is needed.

• Risk of accidents. Questioning should uncover risks that

could lead to falls, motor vehicle accidents, suffocation

or fire/burns and poisoning. These account for most

unintentional deaths among older adults.

• Medication compliance. Ask older patients who are still

administering their own medications to bring them to

the next office visit to explain what each pill is and how

it is taken. An older adult with vision problems once

showed that he drew up the correct amount of insulin

based on “how heavy it should feel” in the syringe.

Advise caregivers that older patients with dementia

may need supervision or assistance with timely refills,

requesting prescriptions, arranging medications in a

weekly organizer or even daily administration. Although

using medication patches sounds simple, changing

them daily or weekly may require direct supervision.

Creams may need to be applied for the patient.

Prescribing medications that require patients with

dementia to sit up for 30 minutes and avoid food or

other medications right away may be inappropriate.

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• Sleep aids/alcohol misuse. All older adults can become

inattentive and nervous after the death of a spouse or

close friend. Some request sleep aids or medications

for anxiety. Ask whether older patients with dementia

have such a prescription from another physician or use

pain medications prescribed for a deceased spouse.

Continued use of such medications can mask underly-

ing depression, or cause cognitive problems or falls.

It’s also important to clarify to what extent a depressed

older patient is using alcohol. Alcohol intake, particu-

larly at night, causes sleep disruption, and the patient

may not share this habit with the physician. There may

be a higher risk for suicide in older adults consuming

alcohol as well.

Potential interventions

Evaluations of the home setting by occupational, physical

and/or speech therapists and a social worker should be

recommended routinely during various stages of demen-

tia because the needs of patients and caregivers change.

evaluations can help with:

• Bathing. An occupational therapist ordered to evaluate

the home setting may suggest that caregivers use soap-

less washes and bathing caps, warm up the bathroom

with a heater prior to asking the patient to disrobe, or

distract the patient with big band music to de-escalate

a situation.

• Eating. Speech therapists may suggest changes in

the consistency of food when dementia impairs swal-

lowing ability.

• Accident/fall prevention. Occupational or physical thera-

pists may suggest home modifications for safety.

• Driving. It’s important to ask if an older patient with

dementia is driving. Caregivers may be concerned about

the patient driving but may avoid confronting the issue.

There may be collusion if the caregiver spouse is not a

licensed driver. Even minor accidents signal a need for

a driving assessment and the need to alert caregivers to

arrange other transportation.

• Physical safety. Any patient with dementia who cannot

reliably initiate a call to 911 or utilize a lifeline button

should not be left alone by a caregiver. Patients who do

not exhibit safety precautions when transferring weight

or negotiating stairs also need 24/7 supervision.

understanding caregiver constraints

A thorough understanding of who provides care for the

older patient with dementia — and the type and frequency

of care they provide — is critical. Many family caregivers

vastly underestimate the care that older adults with demen-

tia need, particularly if they live apart from the patient.

One-third to one-half of patients with dementia have

no identifiable caregiver. When care is provided, more

than 80 percent is provided by family caregivers. spouses

account for the majority of caregivers living with older

adults with dementia, followed by adult children.

Fifteen percent of unpaid caregivers for those with

Alzheimer disease and other dementias live more than two

hours away, and 30 percent of caregivers also provide care

for other dependents. Detection of potential problems may

be compromised when one or more individuals provide

care for an older patient with dementia.

Overwhelmed caregivers need guidance from physicians

about what to monitor and what to report so that timely

intervention can be implemented. n

Ms. Truchanowicz, of Cleveland Clinic’s ob/gyn & Women’s Health Institute, can be reached at 216.445.8701 or at truchar@ccf.org.

G e r I AT r I C T I M e s | FA L L 2 0 1 3

Evaluating the Older Patient with Dementia continued

In Part 2 of this series on SOS, Ms. Truchanowicz will address outlook on life and support networks. Look for it in our next issue of Geriatric Times.

14

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Geriatric Medicine Staff

gERiATRiciAnS AnD gERiATRic PSycHiATRiSTS in THE clEvElAnD CLInIC HEALTH SySTEM

MAIn CAMPuS

Ronan factora, MD Do gyun Kim, MD Amanda Lathia, MD Barbara Messinger-Rapport, MD, PhD Steven Schwartz, MD Quratulain Syed, MD Anne vanderbilt, cnS, cnP

Avon LAKE fAMILy HEALTH CEnTER

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BEACHWooD fAMILy HEALTH AnD SuRgERy cEnTER

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EucliD HOSPiTAl

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FAiRviEW HOSPiTAl

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lAKEWOOD HOSPiTAl/luTHERAn HOSPiTAl

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lORAin inSTiTuTE

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clEvElAnD clinic FlORiDA

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JoInT APPoInTMEnTS WITH THE CEnTER foR gERIATRIC MEDICInE

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DigESTivE DiSEASE inSTiTuTE

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EMERgEnCy SERvICES InSTITuTE

fredric Hustey, MD

EnDOcRinOlOgy & METABoLISM InSTITuTE

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gLICKMAn uRoLogICAL & KiDnEy inSTiTuTE

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HEAD & nEcK inSTiTuTE

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nEuROlOgicAl inSTiTuTE

Charles Bae, MD Karen Broer, PhD neil Cherian, MD Kathy Coffman, MD Kathleen franco, MD Richard Lederman, MD, PhD Mark Luciano, MD, PhD Richard naugle, PhD Leo Pozuelo, MD Babak Tousi, MD Brinder vij, MD

Brain Tumor and neuro-Oncology gene Barnett, MD glen Stevens, DO, PhD

Physical Medicine and Rehabilitation frederick frost, MD vernon Lin, MD, PhD

oB/gyn & WoMEn’S HEALTH InSTITuTE

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ORTHOPAEDic & RHEuMAToLogIC InSTITuTE

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Mellar Davis, MD Mona gupta, MD Terence gutgsell, MD Abdo Haddad, MD Susan Legrand, MD Armida Parala-Metz, MD Dale Shepard, MD, PhDAll physicians in Regional Geriatrics have joint appointments

in the Center for Geriatric Medicine.

The Cleveland Clinic FoundationGeriatric Times9500 euclid Ave./AC311Cleveland, OH 44195

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